PHC4 FYI - The Nursing Shortage: A Reason for Concern?

A variety of studies demonstrate that the nursing shortage in Pennsylvania mirrors the national situation. According to the Hospital and Healthsystem Association of Pennsylvania (HAP), some reasons for the shortage are the deteriorating financial condition of hospitals and health systems; an economy that has provided increased opportunities for employment outside of health care; the aging of the workforce; and improved medical knowledge and technology that enables treatment (not previously available) of chronically ill or severely injured patients. Nursing groups add nursing job dissatisfaction and burnout as a root cause. The aging population has led to increased demand for health services. Some economists also suggest the pay scale does not compensate for the high stress level - particularly in an economy offering well-paid, lower stress occupations.

Nurses represent the largest group of health care workers in hospitals, and thus, the shortage of nurses can potentially affect access to care. HAP and the nursing community share many concerns about the shortage. Hospitals and professional organizations are implementing measures to attempt to reverse the trend toward increasing nurse vacancies and the departure of nurses from the hospital setting. Short-term financial incentives and marketing strategies may help, but these measures increase operating budgets. Longer term, nurses, hospitals and other health care stakeholders say changes in the nursing and health care environment are needed. This paper looks briefly at these issues.

The American Hospital Association estimated in June 2001 that 126,000 U.S. nursing positions were unfilled. It is estimated that by the year 2020, the gap could widen to at least 400,000 nurse vacancies. The nurse vacancy rate in Pennsylvania hospitals was estimated to be 11 percent for fiscal year 2001, according to a March 2002 report from HAP. This is higher than the average nurse vacancy rate of 9.3 percent for the northeastern United States as reported by the American Organization of Nurse Executives (AONE) in its 2000 report.

In an independent poll of nurses in Western Pennsylvania commissioned by District 1199P/Service Employees International Union earlier this year, more than 75 percent of the nurses responded that staffing in their units was inadequate to meet patients' needs. Ninety-four percent said that inadequate staffing is why there is a shortage of nurses willing to work in hospitals.

A compelling reason to address the current nursing shortage is the correlation between hospital nurse staffing and quality of care, demonstrated by a nationally recognized article published recently in the Journal of the American Medical Association. Led by Linda Aiken at the University of Pennsylvania School of Nursing, the large-scale study used PHC4 data merged with other data. The researchers found a correlation between nurse-to-patient ratios and risk-adjusted thirty-day mortality rates in surgical patients. For each additional patient in a nurse's caseload, the study found there is a seven percent increase in the likelihood of a patient dying within 30 days of admission; a 23 percent increase in the likelihood the nurse will develop burnout; and a 15 percent increase in the likelihood the nurse will experience job dissatisfaction. The Aiken study also demonstrates that heavy workloads and mandatory overtime are contributing to a nurse burnout rate of 40 percent, a rate that exceeds the norm for the health care industry.

A survey released in November 2002 by the Pennsylvania Department of Health, Special Report on the Characteristics of the Registered Nurse Population in Pennsylvania (DOH study), noted the average age of a Registered Nurse (RN) working in direct patient care is 45.9 years. Almost 89 percent of the RNs employed in Pennsylvania as of April 2002 were age 35 or older, according to the DOH study, and only 11 percent were ages 20-34.The same study said that 25 percent of the total Pennsylvania population is between ages 20 and 34. Aging of RNs in the health care environment is a concern because the number of persons entering the profession is insufficient to fill the existing and projected needs - the number of nurse vacancies is growing.

According to a December 2002 survey released by the American Association of Colleges of Nursing (AACN), enrollment in entry-level baccalaureate programs in nursing increased by 8 percent in 2002 over 2001. On the other hand, enrollment in programs that enable RNs with a hospital diploma to earn a bachelor's degree and enhance their skills (RN-to-baccalaureate programs) declined 2.1 percent, continuing a downward trend that began in 1999. The Pennsylvania State Nurses Association (PSNA) says there is a waiting list for nursing school slots because there are not enough faculty or clinical sites. PSNA sponsored a summit meeting on the nursing shortage in August, and has a leadership platform on its website.

The consequences of the nursing shortage are far reaching, not only for the delivery of care, but also in terms of financial viability and profitability. According to a recent Voluntary Hospitals of America (VHA) report, The Business Case for Work Force Stability Study, hospitals with high turnover rates have higher than average cost-per-discharge rates and substantial decreases in profitability. VHA said that the effect of overworked, burned out and dissatisfied nurses, as well as delays in the delivery of care could affect the overall quality of care delivered, and might play a role in influencing patient satisfaction. Furthermore, these factors could possibly have negative impacts on the market share of hospitals.

Hospitals across Pennsylvania are using a variety of approaches in recruitment and retention of nurses, including schedule flexibility, involvement of nurses in decision making regarding the work environment, commitment to professional development through tuition reimbursement and payment for continuing education. To encourage people to choose nursing careers, the federal Nurse Reinvestment Act, signed into law on August 1, 2002, established nursing scholarships, retention initiatives, patient safety enhancements and loan cancellation. Closer to home, the Pennsylvania Higher Education Assistance Agency (PHEAA) has developed the program, Nursing Loan Forgiveness for Healthier Futures, which could reduce student loan payments for more than 12,000 state nursing students.

To help address the issue of the aging nurse population, ergonomic standards and new technologies are being adopted to prevent back injuries - the most common workplace injury - by providing assistance with daily care, lifting of patients, and other related activities that require physical exertion.

When nurses have more autonomy, status and control, their behaviors on behalf of patients result in better outcomes, according to the Institute of Medicine assessment of the nursing shortage, Nursing Staff in Hospitals and Nursing Homes: Is it Adequate? One example is The Magnet Recognition Program, accredited through a subsidiary of the American Nurses Association. The Magnet Program establishes hospital levels of excellence by encouraging characteristics such as critical thinking, leadership, flexibility, autonomy, and teamwork. Research indicates that patients experience lower mortality rates, shorter lengths of stay and increases in satisfaction if they receive their care at a Magnet hospital. Health care facilities also benefit, particularly in their ability to attract new nurses.

Health care providers cannot respond to these challenges alone. As HAP suggests, to assure continued access to care, both the private and public sectors need to be vested in finding real and lasting solutions. This requires a committed, collaborative effort of nursing leadership, the health care community, purchasers, and policy makers to develop creative solutions and sustained, effective plans. A positive workplace culture that incorporates Magnet Recognition Program principles, nurse retention incentives, continued education investment, creative staffing schedules, and investment in technology to assist in care delivery could be useful. Pennsylvania should take a comprehensive approach to the collection and analysis of health care workforce data and information, particularly concerning the supply and demand for nurses across the full continuum of health care. Ultimately stakeholders, including purchasers, must acknowledge and accept the responsibility and accountability to lead the nursing profession to prominence as a desirable and rewarding career.

Other Resources

Aiken, L. et al. Hospital Nurse Staffing and Patient Mortality, Nurse Burnout, and Job Dissatisfaction. JAMA, October 23/30, 2002. Along with 30-day risk adjusted mortality and failure to rescue rate, nurse burnout and job dissatisfaction are associated with nurse-to-patient ratio. Nurse burnout out is forty percent, which exceeds the norms for the health care industry. Job dissatisfaction among hospital nurses is 4 times greater than the average for all US workers. This article used PHC4 data along with other data as their database for the study.

Aiken, LH, Clarke SP, Sloane DM, et al. Nurses' Reports on Hospital Care in Five Countries. Health Affairs2001; 20(3): 43-53.The current nursing shortage, high hospital nurse job dissatisfaction, and reports of uneven quality of hospital care are not uniquely American phenomena. This paper presents reports from 43,000 nurses from more than 700 hospitals in the United States, Canada, England, Scotland, and Germany in 1998 1999. Nurses in countries with distinctly different health care systems report similar shortcomings in their work environments and the quality of hospital care. Core problems in work design and workforce management threaten the provision of care.

Needleman, J. et al. Nurse-staffing Levels and the Quality of Care in Hospitals. NEJM, Vol. 346, No. 22The higher proportion of hours of nursing care provided by registered nurses and a greater number of hours of care by registered nurses per day are each associated with better care for hospitalized patients.

Kover, K. Nurse Staffing and Postsurgical Adverse Events: An Analysis of Administrative Data from a Sample of U.S. Hospitals, 1990-1996. Health Services Research 37:3 (June 2002).Relationship between pneumonia and other adverse events and the nursing staff ratios are consistent with existing literature. Study provides meaningful information of staffing levels and ideas on the optimal nursing level to provide high-quality, cost-effective care. More data and research is needed in this area.